• Compliance Matters

    New CPT Evaluation Codes Are Here

    What you need to know about the changes.

    Effective January 1, 2017, Current Procedure Terminology (CPT; ©American Medical Association) code 97001 (physical therapy evaluation) was deleted from the AMA CPT code book and replaced with 3 new tiered codes designed to enable physical therapists (PTs) to better describe the complexity of patients' and clients' clinical presentation and other important contextual factors affecting their outcomes. Code 97002 (physical therapy reevaluation) also was deleted and replaced with a new reevaluation code.

    Despite the recommendation of AMA's Relative Value Scale Update Committee (AMA RUC), the Centers for Medicare and Medicaid Services (CMS), in the 2017 physician fee schedule, priced the new evaluation codes as a group—using the same value for all 3 codes—rather than stratifying them. CMS says it will collect and analyze utilization data on the new evaluation codes during 2017 to help determine possible future changes in payment policy. This means that even though the code values weren't stratified for 2017, it's critical for PTs to be thoughtful in choosing the most accurate code for each examination, as CMS potentially will use the data when and if it does decide to establish tiered payment.

    Here are some key facts to help you start using the codes correctly.

    The New Codes

    Code 97161 (physical therapy evaluation, low complexity) denotes:

    • A history of the present illness or problem, citing no personal factors and/or comorbidities that affect the plan of care;
    • A limited examination of the affected body area or organ system, using standardized tests and measures addressing 1 or 2 of the following: body structures and functions, activity limitations, and/or participation restrictions;
    • A clinical presentation featuring stable and/or uncomplicated characteristics; and
    • Clinical decision making of low complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

    This level of evaluation typically will require 20 minutes face-to-face with the patient or client and/or family.

    Code 97162 (physical therapy evaluation, moderate complexity) denotes:

    • A history of the present illness or problem that includes a review of the pertinent body system and cites 1 or 2 personal factors and/or comorbidities that affect the plan of care (potential factors include sex, age, coping style, social background, education, profession, past and current experience, overall behavior pattern, character, and other elements that may influence how disability is experienced by the individual);
    • An examination of the affected body area or organ system and other symptomatic or related areas and systems, using standardized tests and measures to address a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
    • An evolving clinical presentation, featuring changing characteristics; and
    • Clinical decision making of moderate complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

    This level of evaluation typically will require 30 minutes face-to-face with the client and/or family.

    Code 97163 (physical therapy evaluation, high complexity) denotes:

    • A history of the chief problem (review extended to a limited number of additional body systems and to pertinent past, family, and/or social history) that includes 3 or more personal factors and/or comorbidities that affect the plan of care;
    • An examination of the applicable body system or systems, using standardized tests and measures to address a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
    • A clinical presentation featuring unstable and unpredictable characteristics; and
    • Clinical decision making of high complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

    This level of evaluation typically will require 45 minutes face-to-face with the patient or client and/or family.

    Code 97164 (physical therapy reevaluation) denotes:

    • An examination including a review of history and use of standardized tests and measures; and
    • A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

    The reevaluation typically will require 20 minutes face-to-face with the patient or client and/or family.

    One thing to note is that the typical times listed for each code are for guidance only; these are not timed codes. The amount of time spent with the patient or client for an examination can vary greatly at any of the 3 levels of complexity.

    Frequently Asked Questions

    Why did 3 new CPT codes replace the single evaluation code 97001? The federal government and leading policy groups had been discussing needed reforms to therapy payments under federal programs. In June 2013, a report from the Medicare Payment Advisory Commission (MedPAC)1 included payment reform recommendations for physical therapy under Medicare. These recommendations included payment reductions, access limitations, and utilization controls.

    In addition, increasing regulatory and legislative burdens on physical therapy providers spurred APTA to more aggressively pursue alternative payment and coding methods to help ease or prevent policies that negatively affected payment for physical therapist services.

    APTA recognized that the health care system was in the process of transitioning from being based on the volume of services to being value-based. Revising the physical medicine and rehabilitation (PM&R) evaluation codes to a patient management coding system starts positioning physical therapy as an integral component of new, value-based health care. A first step was revising the evaluation codes within the PM&R code set.

    (For more on how coding changes fit into the larger picture of health care reform, see "Coding Reform, to Payment Reform, to Health Care Reform" in the April 2016 issue of PT in Motion.2)

    To which providers, settings, and entities do these new codes apply? The new CPT codes apply to PTs and others providing therapy services in outpatient Part B settings that are billed to third-party payers using CPT codes. Beyond PTs, all entities covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), such as federal and commercial payers, must use the new codes. (Workers' compensation programs and auto liability carriers are not required to acknowledge the new codes, as they are exempt from HIPAA.)

    What changes must I make to my practice to implement the new CPT codes—for example, in such areas as staff training and electronic medical records (EMR)? Staff must be trained on the new coding system. Because the new system has 3 levels of evaluation, PTs must be able to distinguish among varying patient presentations in order to select the appropriate code level. EMR must be updated to incorporate the new codes, and outdated CPT evaluation and reevaluation codes must be removed from EMR systems.

    Will documentation requirements change with these new CPT codes? Yes, most likely. Look to APTA's website for updates on this. In the meantime, as with the old codes PTs should ensure that their documentation supports the services they are performing and the code they are billing. PTs also should document the clinical reasoning behind their choice of code level, including support for the selected code based on the patient's presentation.

    Of note, in response to APTA's comments that PTs should not be unduly penalized by Medicare administrative contractors during medical reviews while becoming familiar with the new code set, CMS has delayed changes to the Medicare Benefits Policy Manual (MBPM) related to documentation instructions for physical therapy evaluations and reevaluations. CMS reminds PTs, however, that they are expected to comply with the existing MBPM instructions for evaluation and reevaluations that were in effect for the old evaluation codes.

    How will value/outcomes be measured for my patients under this new system? Codes are 1 part of the system for reporting services for the purpose of payment. The new coding system does not measure outcomes on its own; it must be paired with outcomes measures. The coding language (refer back to the descriptions under each new code number earlier in this column) does incorporate use of standardized tests and measures to help the physical therapy profession begin to report standardized data elements. This enables outcomes, and ultimately the value of physical therapy, to be measured in a more uniform manner.

    Can the new codes be billed on the same day as other therapeutic procedures? Neither the CPT Handbook nor the National Correct Coding Initiative (NCCI) restricts PTs from billing the new evaluation codes on the same day as other therapeutic procedures, and many third-party payers follow the same regulations. However, billing the new codes along with some existing codes may require modifier -59 to indicate that the procedures are separate and distinct services. APTA's NCCI webpage (http://www.apta.org/Payment/Medicare/CodingBilling/CCI/) includes a link to the NCCI resource that lists the affected code pairs.

    For reevaluations, CMS bundled the old reevaluation code (97002) with all of the 97000-series therapy codes. This means if PTs performed a reevaluation during the same visit as any therapeutic procedure, they could bill for both services using the -59 modifier. This edit likely will apply to the new reevaluation code, 97164, as well. The reevaluation must be medically necessary and distinctly separate from the therapeutic procedure, and the distinction must be clearly indicated in the documentation.

    In addition, indications for a reevaluation are new clinical findings or the patient's failure to respond to interventions, which could lead to a change in the plan of care. While patients are assessed at each visit, it is unusual to perform or bill for a complete reevaluation.

    What is the payment rate for the new evaluation codes? All 3 new evaluation codes retain the same relative value unit that the old 97001 code held (1.20). The new 97164 reevaluation code was revalued at 0.75, up from the 0.60 value of the old 97002 code. CMS established these rates under the 2017 Medicare physician fee schedule, which took effect on January 1. Third-party payers generally published their new payment rates after the release of the fee schedule last November. PTs should contact these payers directly for their current fee schedules.

    Who should I contact if I have problems being paid when I bill using the new codes? Start by getting in touch with the payer to ensure that it is aware of the coding changes. For Medicare-related issues, get in touch with the Medicare administrative contractor in your area.

    Should you continue to have problems, contact APTA's advocacy team at advocacy@apta.org.

    Where can I find more information about the new codes? APTA continually updates its payment reform webpage that specifically pertains to the new codes. Visit www.apta.org/PaymentReform/NewEvalReevalCPTCodes/. There also is a discussion forum within APTA's online Payment Reform Hub community for members to share their insights and ask staff experts their questions on the new evaluation codes. It's open to all APTA members and is accessible with APTA member login by going to the Hub (http://communities.apta.org/p/us/in/), then the Payment Reform community, then New Evaluation and Reevaluation Codes Discussion.

    Elliott, Carmen

    Carmen Elliott, is vice president of payment and practice management at APTA.  

    References

    1. Medicare Payment Advisory Commission. June 2013 Report to the Congress: Medicare and the Health Care Delivery System. http://www.medpac.gov/-documents-/reports?op=AND&SortBy=YEAR&SortDirection=DESC&FilterByYear=2013. Accessed November 28, 2016.
    2. Coding reform, to payment reform, to health care reform. PT in Motion. 2016;8(3):26-32.

    Resources

    American Physical Therapy Association

    Centers for Medicare & Medicaid Services


    Comments

    the pediatric population does not fit well into this model. I have never done a re-evaluation in 20 minutes. I usually need to spend 45 minutes to an hour with the patient and then the time to write a report that is anywhere from 6 to 10 pages long.
    Posted by Ouida Wellenberger on 2/17/2017 5:10:09 PM

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